Page 332 Acute Pain Management

Percutaneous vertebroplasty
Where other measures fail, percutaneous vertebroplasty is a minimally invasive procedure
that aims to stabilise vertebral compression fractures by the injection of bone cement
(polymethylmethacrylate) and achieve rapid pain relief. Two systematic reviews suggested
that both vertebroplasty and kyphoplasty procedures for osteoporotic vertebral lesions were
effective and safe (Hulme et al, 2006 Level I; McGirt et al, 2009 Level I). However results of more
recent randomised‐controlled trials found no benefit from these procedures compared with
conservative management (Buchbinder et al, 2009 Level II; Kallmes et al, 2009 Level II).
Data to support these procedures for malignant bone lesions relies on low level evidence
(Cheung et al, 2006 Level IV; Pflugmacher et al, 2006 Level IV; Ramos et al, 2006 Level IV Anselmetti et
al, 2007 Level IV; Brodano et al, 2007 Level IV; Calmels et al, 2007 Level IV; Chi & Gokaslan, 2008
Level IV; Masala et al, 2008 Level IV). All suggest a role for vertebroplasty for rapid relief of
intractable pain and restoration of function in vertebral malignancy, and a low complication
rate with experienced operators. An adverse event rate of 6.8% has been reported, including
haematoma, radicular pain, and pulmonary embolism of cement (Barragan‐Campos et al, 2006
Level IV).
Cementoplasty procedures for intractable pain also extend to percutaneous injection of bone
cement under fluoroscopic guidance into pelvic bone malignancies, including metastases or
sarcoma involving acetabulum, superior and inferior pubic rami, ischium and sacrum (Weill et
al, 1998 Level IV; Marcy et al, 2000; Kelekis et al, 2005 Level IV; Harris et al, 2007 Level IV).

9.7.6 Other acute cancer pain syndromes
Other acute pain syndromes in patients with cancer include malignant bowel obstruction and
mucositis.
Malignant bowel obstruction
Malignant bowel obstruction may present with generalised abdominal pain or visceral colicky
pain. Very little trial data exists to guide choices between best medical care, surgery or
endoscopic interventions.
Pharmacological management is based on analgesic, antiemetic and antisecretory agents.
CHAPTER 9 Acute pain in malignant bowel obstruction is best managed with parenteral opioids, which
also reduce colicky pain by reducing bowel motility (Anthony et al, 2007). The parenteral route
is utilised due to the unpredictability of absorption of oral medications. For exacerbations of
colic, the antispasmodic hyoscine butylbromide is of benefit and less sedating than hyoscine
hydrobromide (Anthony et al, 2007; Ripamonti et al, 2008 Level IV). Decompression and reduction
in secretions may also assist with pain. In patients with inoperable malignant bowel
obstruction and decompressive nasogastric tube, both hyoscine butylbromide and the
somatostatin analog octreotide reduced both continuous and colicky pain intensity
(Ripamonti et al, 2000 Level III‐1). A Cochrane Database systematic review revealed a trend
for improvement in bowel obstruction after dexamethasone (Feuer & Broadley, 2000 Level I).
For malignant bowel obstruction with peritoneal carcinomatosis, treatment according to a
staged protocol with analgesic, antiemetic, anticholinergic and corticosteroid as initial therapy
(Stage 1), followed by a somatostatin analog for persistent vomiting (Stage 2) and then venting
gastrostomy (Stage 3) was highly effective in relieving symptoms and avoiding permanent
nasogastric tube, in one hospital centre (Laval et al, 2006 Level IV).
Whereas laparotomy may not always be an appropriate treatment option, endoscopic stenting
may offer effective and safe palliation or act as a bridging step before surgery; analysis of
many retrospective case series, single case reports and reviews indicated a wide variation in

284 Acute Pain Management: Scientific Evidence